Incidence, Predictors, and Outcomes of Paravalvular Regurgitation After TAVR in Sievers Type 1 Bicuspid Aortic Valves.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) in patients with bicuspid aortic valve (BAV) stenosis is technically challenging and is burdened by an increased risk of paravalvular regurgitation (PVR). OBJECTIVES: The aim of this study was to identify the incidence, predictors, and clinical outcomes of PVR after TAVR in Sievers type 1 BAV stenosis. METHODS: Consecutive patients with Sievers type 1 BAV stenosis undergoing TAVR with current-generation transcatheter heart valves (THVs) in 24 international centers were enrolled. PVR was graded as none/trace, mild, moderate, and severe according to echocardiographic criteria. The endpoint of major adverse events (MAEs), defined as a composite of all-cause death, stroke, or hospitalization for heart failure, was assessed at the last available follow-up. RESULTS: A total of 946 patients were enrolled. PVR occurred in 423 patients (44.7%)-mild, moderate, and severe in 387 (40.9%), 32 (3.4%), and 4 (0.4%) patients, respectively. Independent predictors of moderate or severe PVR were a larger virtual raphe ring perimeter (adjusted OR: 1.07; 95% CI: 1.02-1.13), severe annular or left ventricular outflow tract calcification (adjusted OR: 5.21; 95% CI: 1.45-18.77), a self-expanding valve (adjusted OR: 9.01; 95% CI: 2.09-38.86), and intentional supra-annular THV positioning (adjusted OR: 3.31; 95% CI: 1.04-10.54). At a median follow-up of 1.3 years (Q1-Q3: 0.5-2.4 years), moderate or severe PVR was associated with an increased risk of MAEs (adjusted HR: 2.52; 95% CI: 1.24-5.09). CONCLUSIONS: After TAVR with current-generation THVs in Sievers type 1 BAV stenosis, moderate or severe PVR occurred in about 4% of cases and was associated with an increased risk of MAEs during follow-up.

Unconventional treatment of a giant coronary aneurysm presenting as ST-elevation myocardial infarction: a case report.

BACKGROUND: The optimal treatment of aneurysmal or ectatic culprit vessels in the setting of acute myocardial infarction is still matter of debate, as revascularization with either percutaneous intervention or surgery is associated with low procedural success and poor outcomes. CASE SUMMARY: We report the case of a 55-year-old male patient, admitted for inferior ST-elevation myocardial infarction, who underwent successful percutaneous implantation of a micro-mesh self-expanding nitinol carotid stent in a right coronary aneurysm with intravascular ultrasonography measured diameter of 9 mm and massive thrombus apposition. DISCUSSION: The technical characteristics of the micro-mesh self-expanding nitinol carotid stent allow for adequate plaque coverage and good apposition even in large vessels, making this device particularly suitable for the treatment of coronary lesions with high thrombus burden, when severe coronary ectasia or aneurysms are present.

Clinicoradiological Profile and Functional Outcome of Acute Cerebral Venous Thrombosis: A Hospital-Based Cohort Study.

Introduction Acute cerebral venous thrombosis (CVT) may result in a variety of clinical presentations, with headache being the most common. The relationship between clinical and neuroradiological characteristics in acute CVT patients is still not univocally characterized. Materials and methods We enrolled 32 consecutive acute CVT patients admitted to our emergency department from January 1, 2012, to June 30, 2019. Clinicoradiological associations and their relationship with the functional outcome at the discharge were tested. Results Headache was the presenting symptom in 85% of patients, more frequently subacute (82%), new-onset (67%), with unusual features in respect to prior headache episodes (100%), and associated with concomitant neurological symptoms/signs (74%). Patients with holocranial headache showed more frequent venous ischemia (VI) compared to those with bilateral and unilateral headache (50% vs. 20% vs. 0%, respectively; p=0.027). Patients with concomitant neurological defects had a higher prevalence of VI (50.0% vs. 15.0%; p=0.049) and superior sagittal sinus thrombosis (67% vs. 30%; p=0.043) than those without. Vomit was more frequently observed in patients with straight sinus thrombosis (67% vs. 8%; p=0.005). Increasing age and VI were independently associated with poor (modified Rankin scale (mRS) 2-5) functional outcome (odds ratio (OR) = 1.081, 95% confidence interval (CI) 1.004-1.165; p=0.038 and OR = 12.089, 95% CI 1.141-128.104; p=0.039, respectively). Conclusions Our study confirms and enriches available data on the clinicoradiological profile of patients with acute CVT and suggests that increasing age and venous ischemia are independently associated with poor outcomes.

Safety and Feasibility of Transcatheter Aortic Valve Replacement in COVID-19 Patients: A Case Series.

In 2020, the coronavirus disease 2019 (COVID-19) pandemic has led to a decrease in interventional treatment for structural heart disease worldwide. In this context, the management of patients with symptomatic severe aortic stenosis (AS) or bioprosthetic valve dysfunction (BVD) represents a clinical challenge, as a delay in aortic valve replacement procedures may increase short-term morbidity and mortality. We report four cases of TAVR performed in patients with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection. All of them were discharged in good clinical conditions and no adverse events were reported at 30 days follow-up. Our experience suggests that in selected patients with mild SARS-CoV-2 infection and symptomatic native AS or BVD, TAVR has a favorable short-term outcome.

Surgical redo versus transseptal or transapical transcatheter mitral valve-in-valve implantation for failed mitral valve bioprosthesis.

BACKGROUND: Redo surgical mitral valve replacement (SMVR) is the current standard of care for patients with failed bioprosthetic mitral valve (MV). Transcatheter mitral valve-in-valve replacement (TMViV) is arising as an alternative to SMVR in high risk patients. We sought to evaluate procedural safety, early and mid-term outcomes of patients who underwent transseptal TMViV (TS-TMViV), transapical TMViV (TA-TMViV), or redo-SMVR. METHODS: We identified patients with failed bioprosthetic MV who underwent TS-TMViV, TA-TMViV, or SMVR at four Italian Centers. Clinical and echocardiographic data were codified according to Mitral Valve Academic Research Consortium definition (MVARC), except for significant valve stenosis. RESULTS: Between December 2012 and September 27, 2019 patients underwent TS-TMViV, 22 TA-TMViV, and 29 redo-SMVR. TS-TMViV and TA-TMViV patients presented higher mean age and surgical risk scores compared with SMVR group (77.8 ± 12 years, 77.3 ± 7.3 years, 67.8 ± 9.4 years, p < .001; STS PROM 8.5 ± 7.2; 8.9 ± 4.7; 3.6 ± 2.6, p < .001). TS-TMViV procedure was associated with shorter intensive care unit time and total length of stay (LOS) compared with TA-TMViV and SMVR group. There were no differences in MVARC procedural success at 30-days (74.1, 72.7, and 51.7%, p = .15) and one-year all-cause mortality between groups (14.8, 18.2, and 17.2%, p = 1.0). MV mean gradient was similar between TS-TMViV, TA-TMViV, and SMVR groups at 30 days and 12 months. CONCLUSIONS: For the selected patients, TS-TMViV and TA-TMViV are to be considered a valid alternative to redo-SMVR with comparable 1-year survival. TS-TMViV is the less invasive strategy and has the advantage of shortening the LOS compared with TA-TMViV.

Downstream or upstream administration of P2Y12 receptor blockers in non-ST elevated acute coronary syndromes: study protocol for a randomized controlled trial.

BACKGROUND: The optimal timing to administer a P2Y12 inhibitor in patients presenting with a non-ST elevation acute coronary syndrome remains a topic of debate. Pretreatment with ticagrelor before coronary anatomy is known as a widely adopted strategy. However, there is poor evidence on how this compares with administration of a P2Y12 inhibitor after defining coronary anatomy (i.e., downstream administration). Moreover, there are limited head-to-head comparisons of the two P2Y12 inhibitors-ticagrelor and prasugrel-currently recommended by the guidelines. STUDY DESIGN: DUBIUS is a phase 4, multicenter, parallel-group, double randomized study conducted in NSTE-ACS patients designed to compare a pretreatment strategy (including only ticagrelor) versus a downstream strategy (including prasugrel or ticagrelor) and to compare downstream prasugrel with downstream ticagrelor. A total of 2520 patients will be randomly assigned to pretreatment with ticagrelor or to no pretreatment. The PCI group of the downstream arm will be further randomized to receive prasugrel or ticagrelor. The two primary hypotheses are that the downstream strategy is superior to the upstream strategy and that downstream ticagrelor is non-inferior to downstream prasugrel, both measured by the incidence of a composite efficacy and safety endpoint of death from vascular causes, non-fatal MI, or non-fatal stroke, and Bleeding Academic Research Consortium (BARC) type 3, 4, and 5 bleedings. CONCLUSIONS: The DUBIUS study will provide important evidence related to the benefits and risks of pretreatment with ticagrelor compared with a strategy of no pretreatment. Moreover, the clinical impact of using downstream ticagrelor compared with downstream prasugrel will be assessed. TRIAL REGISTRATION: ClinicalTrials.gov NCT02618837 . Registered on 1 December 2015.

Timing of Oral P2Y12 Inhibitor Administration in Patients With Non-ST-Segment Elevation Acute Coronary Syndrome.

BACKGROUND: Although oral P2Y12 inhibitors are key in the management of patients with non-ST-segment elevation acute coronary syndrome, the optimal timing of their administration is not well defined. OBJECTIVES: The purpose of this study was to compare downstream and upstream oral P2Y12 inhibitors administration strategies in patients with non-ST-segment elevation acute coronary syndrome undergoing invasive treatment. METHODS: We performed a randomized, adaptive, open-label, multicenter clinical trial. Patients were randomly assigned to receive pre-treatment with ticagrelor before angiography (upstream group) or no pre-treatment (downstream group). Patients in the downstream group undergoing percutaneous coronary intervention were further randomized to receive ticagrelor or prasugrel. The primary hypothesis was the superiority of the downstream versus the upstream strategy on the combination of efficacy and safety events (net clinical benefit). RESULTS: We randomized 1,449 patients to downstream or upstream oral P2Y12 inhibitor administration. A pre-specified stopping rule for futility at interim analysis led the trial to be stopped. The rate of the primary endpoint, a composite of death due to vascular causes; nonfatal myocardial infarction or nonfatal stroke; and Bleeding Academic Research Consortium type 3, 4, and 5 bleeding through day 30, did not differ significantly between the downstream and upstream groups (percent absolute risk reduction: -0.46; 95% repeated confidence interval: -2.90 to 1.90). These results were confirmed among patients undergoing percutaneous coronary intervention (72% of population) and regardless of the timing of coronary angiography (within or after 24 h from enrollment). CONCLUSIONS: Downstream and upstream oral P2Y12 inhibitor administration strategies were associated with low incidence of ischemic and bleeding events and minimal numeric difference of event rates between treatment groups. These findings led to premature interruption of the trial and suggest the unlikelihood of enhanced efficacy of 1 strategy over the other. (Downstream Versus Upstream Strategy for the Administration of P2Y12 Receptor Blockers In Non-ST Elevated Acute Coronary Syndromes With Initial Invasive Indication [DUBIUS]; NCT02618837).

Management and 5-year outcome of patients with coronary artery disease in different periods of stent technology.

BACKGROUND: The availability of bare metal stents (BMS) followed by drug-eluting stents of first- (DES1) and second-generation (DES2) progressively increased the rate of the percutaneous revascularizations [percutaneous coronary intervention (PCI)] with unknown impact on the long-term outcome of real-world patients with established coronary artery disease. We sought to investigate treatments applied in patients with coronary artery disease in BMS, DES1 and DES2 eras and their 5-year outcome. METHODS: A total of 3099 consecutive patients with at least one coronary stenosis more than 50% observed in 2002 (BMS era), 2005 (DES1 era) and 2011(DES2 era) were enrolled at 13 hospitals in Veneto region, Italy. RESULTS: Moving from BMS to DES1 and DES2 eras patients became significantly older, had more comorbidities and received more frequently statins, betablockers, renin-angiotensin modulators and antiplatelets (P < 0.0001 for all). The PCI/conservative therapy ratio increased from 1.9 to 2.2 and 2.3, the PCI/coronary artery by-pass surgery ratio from 3.6 to 4.0 and 5.1. The crude 5-year survival was 84.9, 83.4 and 81.4% (P = 0.20) and survival free of myocardial infarction, stroke or further revascularizations was 62.1, 60.2 and 60.1% (P = 0.68), with cardiovascular mortality accounting for 60.9, 55.6 and 43.4% of deaths. At multivariable analysis cardiovascular mortality was significantly lower in patients enrolled in 2011 vs. 2002 (hazard ratio = 0.712, 95% confidence interval 0.508-0.998, P = 0.048). CONCLUSION: From BMS to DES1 and DES2 eras progressive worsening of patients characteristics, improvement of medical treatment standards and increase in PCI/conservative therapy and PCI/coronary artery by-pass surgery ratios were observed. Five-year outcomes remained similar in the three cohorts, but in the DES2 era cardiovascular mortality was reduced.

Transcatheter Closure of Left Ventricular Apical Pseudoaneurysm with an Amplatzer Vascular Plug.

We report the case of a 66-year-old man, with a history of previous chest radiation therapy admitted to ED for heart failure. The patient was diagnosed with severe aortic stenosis and multivessel coronary disease and underwent surgical aortic valve replacement and coronary artery by pass grafts. Cardiac surgery was complicated by a left ventricular perforation by a venting catheter. The laceration was repaired with a Teflon patch apparently successful. Four months later, a CT scan performed for oncological follow-up demonstrated the complete detachment of the Teflon patch and the formation of a left ventricular pseudoaneurysm. The pseudoaneurysm was effectively treated percutaneously using an Amplatzer Vascular Plug 4.

Transfemoral transcatheter aortic valve implantation for treatment of severe aortic regurgitation in a patient with previous aortic valve-sparing operation according to David.

The regurgitation of the native aortic valve in patient with previous David operation may represent a clinical challenge because the morbidity and mortality risk of re-operation is not negligible. Here we describe the case of a patient suffering from late severe aortic regurgitation, many years after David operation, efficaciously treated with transfemoral transcatheter aortic valve implantation. To the best of our knowledge, this is the first description of such treatment in a patient with aortic regurgitation and previous David operation.

[The use of mechanical chest compression devices for both out-of-hospital and in-hospital refractory cardiac arrest]. / Utilizzo del massaggiatore automatico esterno nell'arresto cardiaco refrattario sul territorio e in ospedale.

The purpose of cardiopulmonary resuscitation after sudden cardiac arrest is to restore minimal blood flow to provide oxygen to the brain and other vital organs. Chest compressions and external defibrillation are the first line for circulatory support. Although early defibrillation is the main factor influencing survival, cardiopulmonary resuscitation must be characterized by high-quality external chest compressions. Unfortunately, the performance of manual chest compressions decreases during time and in hostile conditions. For these reasons, mechanical devices for chest compression are able to support rescuers during cardiopulmonary resuscitation. Commonly used mechanical chest compression devices in Europe include LUCAS and Autopulse. Routine utilization of mechanical chest compression devices cannot be recommended because randomized controlled trials, such as LINC and PARAMEDIC for LUCAS and CIRC for Autopulse, have not demonstrated their superiority compared with manual chest compressions. The aim of this review is to analyze recent data regarding utilization of mechanical chest compression devices, and to clarify advantages and limitations.

[Current practice and changing trends in the percutaneous treatment of structural heart disease. Results of a multicenter survey promoted by the Italian Society of Interventional Cardiology in six Italian Regions including Tuscany, Lombardy, Veneto, Emilia-Romagna, Campania and Puglia]. / Pratica clinica attuale e trend di variazione in cardiologia interventistica strutturale. Risultati di una survey multicentrica SICI-GISE in sei Regioni italiane: Toscana, Lombardia, Veneto, Emilia-Romagna, Campania e Puglia.

BACKGROUND: Significant developments have occurred in the field of percutaneous interventions for structural heart disease over the last decade. The introduction of several innovations has expanded significantly the spectrum of therapeutic applications of structural interventional cardiology. However, the translation of the most recent scientific evidence into clinical practice and the adoption of new technologies may be susceptible to large variability, even within the same geographic area. This study aimed at describing current status and changing trends of structural heart interventions within 6 Regions in Italy. METHODS: Between July 2015 and October 2015, 6 regional delegations of the Italian Society of Interventional Cardiology (SICI-GISE) promoted a web-based multicenter survey concerning structural heart interventions. An ad hoc questionnaire was administered to head physicians of the cath-labs of 4 Regions of Northern Italy (Tuscany, Lombardy, Veneto and Emilia-Romagna) and 2 Regions of Southern Italy (Puglia and Campania). Also, in this study we considered previous data from a similar survey that involved Tuscany, Lombardy, Veneto and Emilia-Romagna between April 2014 and May 2014. Data from the two surveys were compared, observing the changing trends between 2014 and 2015. RESULTS: The 2015 survey was completed in more than two thirds (68%) of the 145 eligible cath-labs. According to the survey, the application of percutaneous structural heart interventions and the availability of devices were wide and homogeneous within the 6 Regions involved. The main factors perceived as limiting the execution of structural heart interventions resulted economic (e.g. cost of procedures and devices) or organizational (e.g. limited diffusion of hybrid operating rooms). CONCLUSIONS: In this study, which was based on the results of a recent survey conducted in 6 Italian Regions, structural heart interventions resulted widely growing throughout the investigated area. The indications for treatment and the availability of devices were relatively homogeneous between the regions involved, as well as the limiting factors, which appear to be mainly economic-organizational.

[Position paper of the Italian Society of Interventional Cardiology (SICI-GISE): antithrombotic therapy in elderly patients with acute coronary syndrome]. / Documento di posizione della Società Italiana di Cardiologia Interventistica (SICI-GISE): terapia antitrombotica nel paziente anziano con sindrome coronarica acuta.

With the ageing of the population in the Western world, an increasing proportion of patients seen in cardiology practice is represented by the elderly. Although approximately one third of patients admitted with acute coronary syndrome (ACS) are >75 years old and the mortality rate in this age group is doubled compared with younger patients, this population is underrepresented in randomized controlled trials and, consequently, clinical guidelines do not always provide clear indications for the management of elderly patients. Therefore, there is an unmet need for clinical guidance regarding this rapidly growing subset of ACS patients, also considering that decisions about optimal antithrombotic treatment strategies in the elderly are often challenging, mostly due to age-related organ dysfunction, the frequency of comorbidities and concomitant medications and an increased risk of both ischemic and bleeding events. A panel of Italian cardiology experts assembled under the auspices of the Italian Society of Interventional Cardiology (SICI-GISE) for comprehensive discussion and consensus development, with the aim to provide practical recommendations, for both clinical and interventional cardiologists, regarding optimal management of antithrombotic therapy in patients with ACS aged ≥75 years. In this position paper, various clinical scenarios in patients with ST-elevation and non-ST-elevation myocardial infarction or unstable angina are presented and discussed, including special subsets (e.g., patients aged ≥85 years, patients with chronic renal disease or previous cerebrovascular events, patients requiring triple therapy or long-term antithrombotic therapy), with the panel's recommendations being provided for each scenario.

[Coronary artery aneurysms]. / Gli aneurismi coronarici.

Coronary artery aneurysms are defined as coronary dilations as greater than 1.5 times the largest diameter of the adjacent coronary segment. They are a relatively rare finding on coronary angiography, with prevalence ranging from 0.3% to 5% depending on case series. The identification of a coronary artery aneurysm is often a dilemma for both the clinician and the interventionist in terms of diagnosis, treatment and follow-up. This review summarizes the etiologic, pathogenetic, clinical and therapeutic aspects of coronary artery aneurysms in the light of the latest research on this topic.

Clinical outcome of patients with de novo coronary bifurcation lesions treated with the Tryton Side Branch Stent. The SAFE-TRY prospective multicenter single arm study.

BACKGROUND: Coronary bifurcation lesions represent a difficult problem regularly confronting interventional cardiologist, in part due to the lack of dedicated device. OBJECTIVE: To investigate the feasibility, safety and effectiveness of the Tryton Side Branch Stent (Tryton Medical, Durham, NC, USA), a dedicated bare metal stent deployed in conjunction with a standard drug-eluting stent to treat bifurcation lesions. METHODS: The SAFE-TRY is a prospective single arm multicenter registry including patients with de novo bifurcation lesions in native coronary arteries and syntax score <32. The primary endpoint was target vessel failure (TVF) at 30 days that comprised cardiac death, target vessel myocardial infarction and clinically driven target vessel revascularization. Secondary endpoints included device, angiographic and procedural success, 9-month major adverse cardiac and cerebrovascular event (MACCE), and stent thrombosis (ST) rates (ClinicalTrials.gov identifier: NCT01174433). RESULTS: Among 252 enrolled patients, 24% had diabetes and 35.3% unstable angina. True bifurcation lesions involving both branches occurred in 96.8% of cases with Medina classification 1.1.1 in 62%. The left anterior descending artery and the left main were treated in 70% and 8.3% of the patients, respectively. A 6 Fr guide catheter was used in 61% of the cases. Device, angiographic and procedural success rates were 99.6%, 99.6% and 97.2% respectively. The 30-day TVF was 2.8%; the 9-month MACCE rate was 13.7%, with target lesion revascularization being 4.4%. No definite ST occurred. CONCLUSIONS: This prospective, multicenter study confirmed the feasibility, safety and effectiveness of the Tryton Side Branch Stent to treat patients with de novo complex bifurcation lesions.

Risk of brain injury during diagnostic coronary angiography: comparison between right and left radial approach.

OBJECTIVES: To assess the incidence of silent cerebral embolization when using the transradial approach for diagnostic coronary angiography (DCA). BACKGROUND: Compared to other vascular access sites, the right transradial approach (RTA) could reduce the amount of brain emboli by avoiding mechanical trauma to the aortic wall caused by catheters and wire, whereas it increases manipulation of catheters in the ascending aorta and has a higher risk of direct embolization into the right common carotid artery. A recent study showed an increased incidence of microembolic signals (MES) in RTA compared to femoral. However, left transradial approach (LTA) has never been assessed. METHODS: 40 patients with suspected coronary artery disease were randomized to DCA via RTA (n=20) or LTA (n=20) with contemporaneous bilateral transcranial Doppler monitoring. RESULTS: MES were detected in all patients, with a significantly higher rate in the RTA group (median 61, interquartile range (IQR) 47-105, vs 48, IQR 31-60, p=0.035). MES generated during procedures needing >2 catheters (n=8), are higher than those detected during procedures performed with 2 catheters (n=32, 102, IQR 70-108, vs 48, IQR 33-60, p=0.001). At multivariate analysis increasing number of catheters was the only independent predictor of high incidence of MES (OR 16.4, 95% CI 1.23-219.9, p=0.034, -2LL=26.7). CONCLUSIONS: LTA has a lower risk of brain embolization because of the lower number of catheter exchange maneuvers. Since the degree of brain embolism depends on the magnitude of mechanical manipulation, catheter changes should be minimized to reduce the risk of cerebral embolization.

Does the site of bleeding matter? A stratified analysis on location of TIMI-graded bleedings and their impact on 12-month outcome in patients with ST-segment elevation myocardial infarction.

AIMS: While bleeding in patients with STEMI undergoing primary percutaneous coronary intervention (pPCI) is known to be associated with poor outcomes, the differential prognostic impact of access-site related versus non access-site related bleedings is unknown. We aimed to assess the relative impact of access-site related bleeding, as compared to non access-site related, on 12-month clinical outcome in patients undergoing intervention for STEMI. METHODS AND RESULTS: Thirty-day bleeding endpoints, stratified into access-site versus non access-site, were examined according to the TIMI scale in 744 patients with STEMI enrolled in the MULTISTRATEGY trial. TIMI major or minor bleeding complications occurred in 56 (7.5%) patients within 30 days, 46% had an access-site related bleed and 34% required blood transfusion. Bleeding severity and the need for transfusion were equally distributed between site access- versus non-site access-related bleeds. After adjustment, patients with any TIMI rated bleed were more likely to die or develop recurrent MI within 12 months (HR 2.1 [95% CI: 1.13-3.8]; p=0.02). This ratio was entirely driven by non-site access-related bleeds (adjusted HR: 2.66 [95% CI: 1.21-5.8]; p=0.007), whereas site-access bleeds were not associated with worse outcomes (HR: 0.74 [95% CI: 0.16-3.4]; p=0.70). CONCLUSIONS: While bleeds of any TIMI severity within 30 days were independently associated with worse cardiovascular outcomes at 12 months, thus confirming previous analyses, this relationship was entirely driven in our study by non access-site related haemorrhagic events. Investigation on whether the site of bleeding complications may preferentially impact cardiovascular outcomes is warranted.

Preliminary experience with optical coherence tomography imaging to evaluate carotid artery stents: safety, feasibility and techniques.

AIMS: Optical coherence tomography (OCT) is an increasingly used intravascular imaging modality to assess coronary stent implantation and vessel healing. A recently developed catheter (C7 Dragonfly; LightLab Imaging Inc.,Westford, MA, USA) allows visualisation of peripheral arteries up to 10 mm of diameter with high speed pullback. Safety, feasibility and the technique of OCT following carotid artery stenting (CAS) were evaluated in the present study. METHODS AND RESULTS: OCT was performed in seven consecutive patients following successful CAS using proximal cerebral protection devices, occluding the common and external carotid artery and gentle manual injection of a total of 8-14 ml of 50% diluted contrast media with normal saline in order to displace the blood from the artery. Once the blood was displaced, pullback was started through the stented segment continuing the gentle contrast injection. After completion of the pullback all injected contrast was aspirated and discarded. In the first three patients, OCT was also performed without internal carotid artery flow blockage. Due to the high blood flow in the ICA it was not possible to replace all residual blood and obtain adequate OCT images. No procedural, in-hospital, or 30-day follow-up complications occurred. One patient experienced transient intolerance to vessel occlusion without any neurological sequels. OCT images were of good quality providing important information regarding stent geometry, presence and lack of strut apposition, plaque fracture, and plaque prolapse. CONCLUSIONS: Intravascular OCT under occlusive proximal protection appears feasible and safe to assess stent implantation in carotid arteries.